ST.

PAUL UNIVERSITY DUMAGUETE

COLLEGE OF NURSING
SY 2020-2021, 2ND SEMESTER
______________________________________________________________________

A Case Study on

Rheumatic Heart Disease Secondary to Acute Rheumatic Fever

Submitted by:

Caren Marie R. Tilos

April 19, 2021

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SY 2020-2021, 2ND SEMESTER
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APPROVAL SHEET
In partial fulfillment of the requirements of the course “NCM
112” this case study entitled, “Rheumatic Heart Disease Secondary to
Rheumatic Fever”.

MR. EVER JOHN N. LAINGO, RN, MAN

Adviser

Accepted with Minor Revision.

Date of Oral Presentation: _______________________________

Noted by:

Cliford Kilat, RN, MAN

Dean, College of Nursing

ACKNOWLEDGEMENT

Above all else, praise and glory to God Almighty for His guidance
and grace which has enabled me to finish the clinical case paper.
    I would like to express my deep and sincere gratitude to our
clinical paper adviser, Mr. Ever John Laingo, RN, MAN, for providing
us with his invaluable guidance and sharing with us his knowledge

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SY 2020-2021, 2ND SEMESTER
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accompanied by his untiring sincerity and motivation which has

inspired us to do more and better in every step as we develop the
paper. It was a great opportunity to work under his guidance which has
significantly helped us to work disciplined while developing and
preparing the content of the paper.
    I also thank my classmates and friends for their stimulating
discussions and for being there with me while making the paper and
spending sleepless nights together and also for assisting me and
answering questions that I have trouble with regarding the clinical
paper.
    I am also extremely grateful to my parents for their
understanding, support, and sacrifices that they have done for my
education and my future. 

CONTENTS

Table of Contents

Chapter I

Abstract 6
Introduction 6-7

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SY 2020-2021, 2ND SEMESTER
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Objectives 7
Scope 8
Limitation 8

CHAPTER II
CASE DATA AND INFORMATION

Patient’s Biographical Data 9

Past Health History 9
Family History 10
Functional Health Patterns 11-12
General Condition 13
Review of Systems 13
Laboratory Examinations 14-16
Diagnostic Imaging Studies 16-17

CHAPTER III
LITERATURE REVIEW

Normal Anatomy and Physiology 18-24

Theoretical Background 25-27

CHAPTER IV
CASE ANALYSIS AND INTERVENTIONS

Pathophysiology 28-31
Medical Management 32
Pharmacologic Management 33-39
Nursing Care Management 40-49
Progress Notes 50
Discharge Plan 51-52

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CHAPTER V
CONCLUSIONS AND RECOMMENDATIONS

Conclusions 53
Recommendations 53
References 54-56

ABSTRACT

Patient M.P.S., a 27-year-old male residing in Malaunay, Valencia

working as a Cargo Checker was admitted to the medical ward due to
complaints of sudden knee pain and swelling that is relieved with
Ibuprofen. The patient was diagnosed with Rheumatic fever, with the
presence of erythema marginatum on the lower limbs and subcutaneous
nodules on the dorsal surface of the hand. The patient was then
started with D5LR 1 L x 33 gtts/min and Ciprofloxacin given through
IVTT, vital signs with O2 sat every 4 hours, laboratory tests were

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taken and Meloxicam 15 mg once daily. The patient was assisted with
proper positioning and handling of affected joint/parts; performed
deep breathing and taught non-pharmacological pain relief strategies.
On a pain scale of 10 out of 10, it has lowered to 7. On the second
day, the patient has complained of slight chest pain and ECG has shown
ST-segment elevation, and follow-up has shown atrial fibrillation. The
doctor has ordered to attach a cardiac monitor and further laboratory
tests were taken. The patient has been advised complete bed rest
without bathroom privileges and was given medications including
aspirin, prednisone, and erythromycin, and troponin result was
negative.

CHAPTER I

CASE OVERVIEW

Introduction

The patient is diagnosed with Rheumatic fever but has later

then progressed to RHD (Rheumatic Heart Disease), it begins with a
sore throat caused by a bacterium called Streptococcus pyogenes (group
A streptococcus), which can quickly spread from person to person in
the same manner as other upper respiratory tract infections do.
Children are the most vulnerable to Strep infections. (World Health
Organization, 2020) Repeated strep infections in certain patients
cause the immune system to attack body tissues, including inflaming
and scarring the heart valves. This is what is known as rheumatic
fever. Rheumatic heart disease develops as a result of rheumatic
fever-induced inflammation and scarring of the heart valves. According
to the most recent WHO statistics released in 2018, the number of
Rheumatic Heart Disease deaths in the Philippines reached 2,781,
accounting for 0.46 percent of all deaths. The Philippines ranks #71
in the world in terms of age-adjusted death rate per 100,000 people.
Rheumatic fever is attributed as the leading cause of heart disease,
accounting for 54.9 % of cardiac children and 46.6 % of cardiac
adults, having an average of 47.1 %.

The patient, a 27-year-old Cargo checker, noted that

approximately 20 days after he had flu-like symptoms he felt joint
pain, the joint pain continued for approximately more than a week
before admission and involved his joints like the elbows, hips, knees,

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and ankles. He was then diagnosed with Rheumatic fever noted with a
history of recurrent flu-like symptoms, has subcutaneous nodules on
the dorsal surface of the hand, and erythema marginatum on the lower
limbs. On the 2nd day of his admission, pt. complained of slight chest
pain and had the physician called. ECG has shown ST-segment elevation
and upon follow-up, has shown atrial fibrillation.

The case about Rheumatic Heart Disease was chosen due to the
method of how each case was randomly chosen for the students. In a
way, each student has a fair probability of being assigned to any of
the potential given cases.

Objectives

o Define Rheumatic Fever and the disease process and how it lead to
Rheumatic Heart Disease
o To discuss the specific case of the patient; his health history,
physical assessment, and functional health patterns
o Explain the pathophysiology and etiology of Rheumatic Heart
Disease
o Develop appropriate nursing management and health teaching
o Apply the developed nursing care plans to the patient
o Demonstrate appropriate nursing interventions specific to the
needs of the patient
o Communicate effectively to the patient and simplify terms for
better and clear understanding about his current health status in
relation to the disease process

Scope

The case involves a 27-year-old patient that was diagnosed with

Rheumatic fever, his health history, functional health pattern,
history of present illness, laboratory results that were taken in the
2-day duty.

Limitation

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The patient was only taken care of for 2 days; further assessment
and patient data progress are unavailable. Some information on patient
family history and functional health patterns was not gathered.

CHAPTER II

CASE DATA AND INFORMATION

Patient’s Biographical Data

Name of Client: MPS

Address: Malaunay, Valencia

Age: 27 years old

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Weight: 50 kg

Birthdate: March 1, 1994

Sex: Male

Religion: March of Faith

Occupation: Cargo Checker

Educational Attainment: Vocational Course

Marital Status: Single

Source of Income: Salary

Date of Admission: March 23, 2021

Diagnosis: Rheumatic Fever

Past Health History

Chief Complaint: “Nikalit lang ug hubag akong tuhod. Mawala if

imnan ug medicol, then mubalik ra pod dayon”

History of Present Illness: The pt. noted joint pains

approximately 20 days after he had flu-like symptoms. He has
experienced joint pain for more than a week already. The pain involved
joints on elbows, hips, knees, and ankles. He took Ibuprofen (Medicol)
to manage the pain but once discontinued, the pain has persisted.
Persistence of pain prompted pt. to seek medical treatment leading to
admission to the medical ward.

Past Health History

Childhood Illnesses: usual cough and colds

Accidents/Trauma: none

Past Hospitalizations: No previous hospitalization experiences

Surgeries: No previous surgeries

Allergies: none

Immunization: Complete immunization

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Family History

? ? ? ?

? hypertensive

patient

Both parents are still alive and Father is hypertensive. The

patient’s father is hypertensive and might have contributed to his
blood pressure having fluctuations but usually being on a range higher
than normal.

Functional Health Patterns

Health Perception and Management

Prior to admission:

The patient takes OTC drugs like Ibuprofen (Medicol) and

Paracetamol (Biogesic) and usually self-medicates. The patient
verbalized the importance of taking care of one’s health but he can
barely keep a healthy lifestyle especially that he always works double
shifts whenever it is offered. The patient usually takes up vitamins,

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especially when he experienced flu-like symptoms, and still takes up

vitamin C.

Nutrition and Metabolism

Prior to admission: The patient describes his diet as typical: rice,

viand, and occasional vegetables. He packs for lunch and rarely eats
at fast-food chains.

During admission: The patient can finish the food served which
consists of rice, fish, or chicken and vegetables. He is restricted
from eating dishes that contain red meat and/or animal organ meats in
his diet.

Elimination

Prior to admission: He usually defecates every morning and he denies

any problem with urination.

During admission: The patient can urinate approximately six (6) times
a day. His urine color is yellow and about two (2) glasses in amount.
His bowel movement is every other day; it could be in the afternoon or
at night.

Activity and Exercise

Prior to admission: After work, he usually plays basketball with his

co-workers.

During admission: The patient does not ambulate since he verbalized

that pain worsens during movement.

Cognitive-Perceptual

Prior to admission: The patient is oriented to time, place, and

people.

During admission: Oriented to time, place, and people; able to respond

to verbal stimuli; has pain felt in his joints; from pain scale of 10
upon admission to 6-7 out of 10.

Sleep and Rest

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Prior to admission: He sleeps 6-8 hours/day except when working a

double shift, in which he sleeps only 4 hours and approximately occurs
3-7 times/month.

Roles and Relationship

Prior to admission: He is responsible for paying the bills at home and

has financial pressure that’s why he takes the chance to work overtime
whenever he can.

Coping and Stress Tolerance

Prior to admission: He describes his work as moderately stressful as

he juggles from paper works to assisting laborers in hauling and
arranging products in the stockroom. His stress relief is through
playing basketball after work and going to the movie theater but due
to the pandemic, he usually plays mobile legends.

Values and Belief

Prior to admission: His religion forbids him to have any vices (like
smoking and alcohol consumption)

During his admission: His religion has no restrictions on the medical

care given.

General Condition

The patient is alert and conversant. The patient’s body is

slightly thin but not emaciated, he is well-kempt. The patient is
oriented about the time, place and can verbalize his condition.

Vital Signs

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March 8:00 AM 12:00 NN March 8:00 AM 12:00 NN

24, 2021 25, 2021
T 36.2 38.5 37.8 T 38.5 37.8
P 89 111 99 P 111 99
R 18 28 21 R 28 21
BP 130/70 150/80 120/90 BP 150/80 120/90

Review of Systems

Integumentary System

There is the presence of erythema marginatum in the lower

extremities and presence of subcutaneous nodules at the dorsal surface
of the hand.

Respiratory System

There are no adventitious breath sounds

Cardiovascular System

The patient is negative for Jugular Vein Distension and no

audible murmurs.

Motor-Musculoskeletal System

There is a presence of pain in joints that transfers from one

area to another. Pain intensifies upon movement.

Laboratory examinations

1. Complete Blood Count

A complete blood count (CBC) is a test that helps evaluate a

person’s overall health and find out if a person has another health issue
e.g. anemia, infection, or leukemia. A CBC measures several components
and features of the blood which include: RBC, which carries oxygen; WBC,
which fights infection; Hemoglobin, oxygen-carrying protein in RBC;
Hematocrit, the proportion of RBC to the fluid component of blood;
Platelets, that help in blood clotting.

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Table 1.1 CBC

Results Normal Remarks

Hct 42% 41%-50% Normal
Hgb 11.1 g/dL 13.5-17.5 g/dL) LOW
WBC 16.2 c/mm3 4.5-11 c/mm3 HIGH
PLT 156 c/mm3 150- 400 c/mm3 Normal

Interpretation: Low hemoglobin is said to be an indication of

continued rheumatic fever activity often attributed to the dilution of
erythrocyte mass by an increased plasma volume. Another reason for
decreased hemoglobin is how the GABHS is associated with the hemolysis
of red cells (Aryal, 2018). With the S. pyogenes, the WBC is high as
it tries to fight off the infection.

2. ESR and CRP

C-Reactive Protein and Erythrocyte Sedimentation Rate are blood

tests used to detect inflammation in the body. CRP appears in plasma
in the event of infectious or inflammatory conditions. ESR increases
when fibrinogen enters in blood and causes red cells to stick to each
other. During the first 24 hours of a disease phase, the ESR may be
normal and the CRP may be elevated, that’s why the CRP is a more
precise and receptive indicator of the acute period of inflammation
than the ESR.

Table 1.2 Biomarkers of Inflammation

Results Normal Remarks

CRP 336 mg/mL <10mg/L High
ESR 108 mm/hr 0-15 mm/hr High

Interpretation: Elevated CRP and ESR only mean that there is a

focal point of inflammation somewhere in the body, but the studies
cannot pinpoint the precise site of inflammation. Elevated ESR and CRP

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levels in pain patients normally return to normal after sufficient

pain relief.

3. BUN and Creatinine

The BUN test is used to aid in the diagnosis of kidney disease as

well as to track patients who have kidney dysfunction or failure. It
can also be used to assess overall fitness. It may be ordered to
assess kidney function prior to certain procedures that may
necessitate the use of medications that may harm the kidneys if not
cleared quickly. Heart failure, dehydration, or a high protein diet
may increase BUN. Having a high creatinine may mean the kidneys are
not properly working.
Table 1.3 BUN and Creatinine
Results Normal Remarks

BUN 17 mg/dL 8-24mg/dl Normal

Creatinine 1.2 mg/dL 0.74-1.35

mg/dl Normal

Interpretation: The BUN and creatinine results are at the normal

level

4. ASO Titer
The Antistreptolysin O test is done on an individual who has
signs of rheumatic fever or glomerulonephritis and a previous history
of sore throat or a reported streptococcal infection.

Table 1.4 ASO Titer

Result Normal Remarks

ASO titer > 800 u/mL <200 High/Increased

Interpretation: An elevated ASO titer (positive ASO) indicates

that the individual has recently had a strep infection.

5. Troponin

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Troponin is the recommended measure for a possible heart attack

since it is more specific for heart failure and stays elevated for
longer than other tests (which may be elevated in the blood with
skeletal muscle injury).

Table 1.5 Troponin

Result Normal

Troponin NEGATIVE NEGATIVE

Interpretation: A series of negative troponin tests indicate that it

is unlikely that the pt.’s heart has been injured.

Diagnostic Imaging Studies

ECG: ST-Segment elevation (Day 2)

Follow-up ECG: Atrial fibrillation

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Interpretation:

The ST segment is the flat, isoelectric section of the ECG

between the end of the S wave (the J point) and the beginning of the T
wave. The ST Segment denotes the time between ventricular
depolarization and repolarization. Myocardial ischemia or infarction
is the most common cause of ST-segment abnormality (elevation or
depression). However, there could be other reasons why a patient
experiences ST-segment elevation, one of these reasons would include
pericarditis, and this ST elevation is believed to be caused by local
inflammatory changes in the epicardium under the inflamed pericardium
and would often be associated with elevated troponin (Teh, et al,
2004).On another note, acute ST-segment elevation changes caused by
hypercalcemia and mimicking a myocardial infarction (with negative
troponin) have been reported on rare occasions, although many believe
it is more common. (Kukla, et al, 2013)

Cardiac troponin although they are undoubtedly vital in risk

stratifying patients with chest pain, they are not without limits.
They take several hours to rise and peak, between 12 and 24 hours. A
second troponin assay should be done 6-12 hours later in patients that
were originally negative for troponin. Furthermore, values will stay
elevated for up to 14 days, reducing their usefulness in diagnosing
reinfarction. (Braunwald, 2000)

Atrial fibrillation is distinguished by the absence of P waves

and an irregularly erratic ventricular rate. Fibrillatory waves or
minute oscillations describe the baseline isoelectric line between QRS
complexes.

CHAPTER III

LITERATURE REVIEW

Normal Anatomy and Physiology

Immune System

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An antibody, also known as immunoglobulin, is a defensive protein

secreted by the immune system in response to the presence of a foreign
material known as an antigen. Antibodies detect and bind to antigens
to eliminate them from the body. The body recognizes a broad variety
of compounds as antigens, including disease-causing species and
poisonous products such as insect venom.

When a foreign agent approaches the bloodstream, the immune

system recognizes it as foreign since the molecules on the antigen's
surface vary from those present in the body. To destroy the invader,
the immune system employs a variety of processes, one of the most
important of which is antibody formation. Antibodies are formed by B
lymphocytes, which are specialized white blood cells (or B cells).
When an antigen binds to the B-cell membrane, it stimulates the B cell
to differentiate and grow into a clone, which is a group of identical
cells. Millions of antibodies are secreted into the bloodstream and
lymphatic system from mature B cells, known as plasma cells.

Antibodies target and neutralize antigens that are similar to the

ones that caused the immune response when they circulate. Antibodies
bind to antigens and attack them. An antibody bound to a toxin, for
example, will neutralize the poison merely by altering its chemical
composition; such antibodies are known as antitoxins. Other
antibodies, by binding to certain invading bacteria, will make them
immobile or block them from entering body cells. In other
circumstances, the antibody-coated antigen undergoes a chemical chain
reaction with complement, which is a set of proteins present in the
blood. The complement reaction may either cause the invading microbe
to lyse (burst) or attract microbe-killing scavenger cells that eat,
or phagocytose, the invader. Once started, antibody synthesis will
continue for several days or until all antigen molecules have been
eliminated. Antibodies can be found in the bloodstream for several
months, supplying prolonged immunity to the specific antigen.

Cardiovascular System

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The heart's wall is made up of three layers of differing

thickness. The epicardium (external layer), myocardium (middle layer),
and endocardium (inner layer) are the three layers of the heart. The
epicardium consists of two tissue layers, which the outermost is known
as the visceral layer of the serous pericardium. It is a thin
transparent layer that is composed of the mesothelium. There is a
variable layer of delicate fibroelastic tissue and adipose tissue
beneath the mesothelium. Adipose tissue is thick in areas over the
ventricular surface and contains the major coronary and cardiac
vessels of the heart. The epicardium has a smooth and slippery texture
on its outermost part. This layer contains blood vessels, lymphatics,
and vessels that supply the myocardium. (Tortora and Derrickson, 2016)

The myocardium which is the middle layer makes up most of the

heart wall for about 95%. (Tortora and Derrickson, 2016) It is the
layer in control of the pumping action of the heart. The muscle fibers
are like the skeletal muscle that are striated and organized in
bundles that swirl diagonally to generate strong pumping actions.

The endocardium covers the valves of the heart with its smooth
lining and is fused to the myocardium with a thin layer of connective
tissue. Previously thought to be a basic lining sheet, recent research
suggests that the endothelium of the endocardium and coronary capillaries
may play important roles in controlling muscle contraction within the
myocardium. (Betts et. al, 2013)

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When the heart contracts, a volume of blood is forced into a

ventricle or out of the heart into an artery. As the heart expands and
relaxes, the valves open and shut in response to pressure changes.
Each of the four valves leads to the one-way flow of blood by opening
to allow blood to pass through and then closing to avoid backflow.
Since the tricuspid and bicuspid valves are between the atrium and
ventricle, they are called atrioventricular valves. (Tortora and
Derrickson, 2016)

As the ventricles begin to contract, the pressure inside the

ventricles increases, and blood flows to the region with the lowest
pressure, which is initially in the atria. The cusps of the tricuspid
and mitral (bicuspid) valves close as a result of this backflow.
Chordae tendineae attach these valves to the papillary muscles. During
the relaxing process of the cardiac cycle, the papillary muscles relax
as well, and the chordae tendinae are slightly tense. However, when
the ventricle's myocardium expands, so do the papillary muscles. This
puts strain on the chordae tendineae, which helps to keep the
atrioventricular valve cusps in place and prevents them from being
blown up into the atria. (Betts et. al, 2013) If the AV valves or
chordae tendinae are injured, blood may regurgitate into the atria
when the ventricles contract. (Tortora and Derrickson, 2016)

Compared to the atrioventricular valves the aortic and pulmonary

semilunar valves don’t have the chordae tendinae and papillary muscle.
Instead, they are made up of pocket-like folds of endocardium that are
lined with extra connective tissue. When the ventricles relax and the
pressure shift pulls blood into the ventricles, the blood pushes into
these cusps and closes the openings. (Betts et. al, 2013)

Nervous System

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Known as basal ganglia, but termed as basal nuclei (by the

Terminologia Anatomica) are found deep within each of the cerebral
hemispheres. There are three nuclei (masses of grey matter), two of
which lie side by side, adjacent to the thalamus. One is the globus
pallidus that is significantly closer to the thalamus and the putamen
is closer to the cerebral cortex. The two nuclei, together are known
as the lentiform nucleus. The third basal nuclei has a large ‘head’
connected to its ‘tail’ by a long comma-shaped ‘body’ and is known as
the caudate nucleus. Known as the corpus striatum, (the lentiform and
caudate nuclei together) refers to the striated appearance of the
internal capsule which passes between the basal nuclei. The substansia
nigra of the midbrain and the subthalamic nuclei of the diencephalon
are the nearby structures of the basal nucleus that can be
functionally linked. Lateral to the putamen is what’s known as
claustrum which is a thin sheet of grey matter. It’s considered a
portion of the basal nuclei by some and its function to humans may not

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be clear but could be involved in visual attention. (Tortora and

Derrickson, 2016)

The basal nucleus’s role is to fine-tune voluntary gestures. They

do this by receiving impulses from the cerebral cortex for future
movement, which they interpret and modify. They send their orders to
the thalamus, which then relays them to the cortex. (Andrusca, 2021)
Prior to eye movements, there is an activity of neurons in the caudate
nucleus; in regulating the muscle tone required for specific body
movements, the globus pallidus helps in the activity. Aside from
influencing motor functions, the basal nuclei also help conduct and
terminate some cognitive processes which include: attention, memory,
and planning; it may also help regulate emotional behaviors along with
the limbic system. (Tortora and Derrickson, 2016)

Integumentary System

A superficial epidermis and a thicker dermis make up the skin's

two main layers. The stratum basale (germinatum) is the innermost
(deepest) layer of the epidermis, followed by the stratum spinosum,
stratum granulosum, stratum lucidum (when present), and the stratum
corneum, which is the outermost layer.

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The stratum corneum, the topmost layer, is made up of dead cells

that shed regularly and are gradually replaced by cells produced from
the basal layer. Melanocytes, cells that manufacture melanin, the
pigment that gives skin its color, are also found in the stratum
basale. To shield cells from UV radiation, melanin is passed to
keratinocytes in the stratum spinosum.

Because of the inclusion of collagen and elastin fibers, the

dermis binds the epidermis to the hypodermis and gives resilience and
elasticity. It is composed of just two layers: the papillary layer,
which has papillae that reach into the epidermis, and the lower,
reticular layer, which is made up of loose connective tissue. The
hypodermis is the connective tissue that binds the dermis to the
underlying components of the skin; it also contains adipose tissue for
fat preservation and defense. (Biga, et al, 2021)

Musculoskeletal System

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The most common type of joint in the body is the synovial joint.
The appearance of a joint cavity is a primary anatomical feature of a
synovial joint that is not found in fibrous or cartilaginous joints.
The articulating surfaces of the bones make contact with each other in
this fluid-filled space. The articular surfaces of bones are coated
with flat articular cartilage at synovial joints. This allows the
bones of a synovial joint to work seamlessly against each other;
resulting in greater joint mobility. The presence of ligaments
strengthens synovial joints. Ligaments connect the bones to prevent
repetitive or irregular joint movement. An articular disc or a
meniscus can also be present in certain joints to provide padding
between the bones. When necessary, muscles and tendons working through
a joint would further boost their contractile strength. (Biga, et
al,2021)

Bursae contain lubricating fluid, which reduces friction between

structures. Subcutaneous bursae are structures that avoid contact
between the skin and an underlying bone. Submuscular bursae keep
muscles from grinding into bones or other muscles. Tendon sheaths
contain a fluid that allows the tendon to move smoothly when it passes
a joint. Based on the form of the articulating bone surfaces, synovial
joints are divided into six groups. Pivot joints allow for side-to-
side rotation of the head as well as radius rotation during forearm
movements. Hinge joints, such as those seen in the elbow, knee, and
foot, or the interphalangeal joints between the phalanx bones of the
fingers and toes, may only flex and straighten. At the base of the
digits (metacarpophalangeal joints) and the wrist is condyloid joints
(the radiocarpal joint). The articulating bones in a saddle joint work
together like a horse and a saddle. Plane joints enable the bones to
slide or rotate against one another, but their range of motion is
generally restricted. The motions between the bones in a ball-and-
socket joint are broad, while the motions between the bones in a plane
joint are limited. (Biga, et al, 2021)

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Theoretical Background

Rheumatic Heart Disease

Rheumatic heart disease is a chronic condition that results from

years after acute rheumatic fever, it is caused by group A beta-
hemolytic streptococci

Risk Factors: poverty, overcrowding, reduced access to medical care

(RHD Australia, 2012)

Clinical Manifestations

The most common sign of acute rheumatic fever is migratory

polyarthritis which is pain felt in one joint then subsides and
transfers to another site. Subcutaneous nodules (deep-seated lesions
in the skin due to accumulation of collagen fibers) and a rash begin
in the trunk to the limbs are created. Rash has a distinctive
erythematic ring with a pale center, known as erythema marginatum.
Sydenham's (St. Vitus' dance) chorea is present and described by the
arms and facial muscles as uncontrollable rapid movements.

The first Rheumatic Fever diagnostic criteria were developed in

1944 by Jones, and then they were modified by AHA (American Heart
Association) in 1992.

Jones Criteria for Rheumatic Fever

Major Criteria Minor Criteria

Carditis (pericarditis, Fever
endocarditis,myocarditis)
Polyarthritis Arthralgia
Sydenham Chorea Prolonged PR interval
Subcutaneous Nodules Increases ESR or CRP*
Erythema Marginatum Leukocytosis
*Erythrocyte Sedimentation Rate or C-reactive protein

** Two major or 1 major and 2 minor must be present to diagnose

rheumatic fever

Some complications of rheumatic heart disease include: (Essop, et

al,2005)

 Heart failure. This can be caused by a severely narrowed or

leaking heart valve.

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 Bacterial endocarditis. This is an infection of the heart's inner

lining. It can happen if the heart valves have been damaged by
rheumatic fever.
 Ruptured heart valve. This is a life-threatening situation. It
requires surgery to replace or repair the heart valve.
 Stroke. RHD patients are at risk for ischemic stroke because blood
clots will form in the heart and obstruct the blood supply to
areas of the brain.
 Arrhythmia. People with RHD are more likely to develop A-Fib
because heart valve trauma alters the structure of the heart,
increasing the chance of AF. Stroke incidence is also greatly
increased by AF.

Management

Medical Management

 Anti-inflammatory. Treatment of the acute inflammatory

manifestations of acute rheumatic fever consists of salicylates
and steroids; aspirin in anti-inflammatory doses effectively
reduces all manifestations of the disease except chorea, and
the response typically is dramatic.

 Corticosteroids. If moderate to severe carditis is present as

indicated by cardiomegaly, third-degree heart block, or CHF,
add PO prednisone to salicylate therapy.

 Anticonvulsant medications. For severe involuntary movements

caused by Sydenham chorea, the doctor might prescribe an
anticonvulsant, such as Valproic acid (Depakene) or
carbamazepine (Carbatrol, Tegretol, others).

 Antibiotics. The doctor will prescribe penicillin or another

antibiotic to eliminate the remaining strep bacteria.

Surgical Management

Surgical care. When heart failure persists or worsens after aggressive

medical therapy for acute RHD, surgery to decrease valve insufficiency
may be lifesaving; approximately 40% of patients with acute rheumatic
fever subsequently develop mitral stenosis as adults.

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The options for surgical management of rheumatic valve disease are

valve repair or replacement with either a bioprosthetic or mechanical
prosthesis. In patients with mitral stenosis, an additional option is
non-surgical percutaneous mitral balloon valvuloplasty.

Nursing Management

 Diet. Collaborate with a nutritionist and advise nutritious

diet, potassium supplementation may be necessary because of the
mineralocorticoid effect of corticosteroid.

 Activity. Initially, place patients on bed rest, followed by a

period of indoor activity before they are permitted to return
to work; do not allow full activity. Monitor the patient’s
response to long-term activity restriction.
 Comfort Measures. Provide comfort measures through relaxation
techniques.
 Observe for the disappearance of any major or minor
manifestation and report any progress.
 Auscultate the heart periodically for the development of a
heart murmur or any friction rub (pericardial or pleural).
 Monitor the patient’s pulse frequently to determine the degree
of cardiac compensation

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CHAPTER IV

CASE ANALYSIS AND INTERVENTIONS

Pathophysiology

Precipitating Factor:

-History of group A beta hemolytic streptococcus pharyngeal

infection

-Lower socioeconomic status

-Poor hygiene

-Malnutrition

-Age (5-15 yrs old)

Etiology:

Group A Beta-hemolytic streptococcus

(Transmission through direct contact

with nasal secretions and saliva)

Presence of Group A beta-

hemolytic streptococcus

Attach to epithelial
cells of the upper
respiratory tract

Activated antigen presenting cells

present the bacterial antigen to
helper T cells
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Helper T cells subsequently

activate B-cells

Production of antibodies against

the cell wall of streptococcus

B cells proliferate and

differentiate into plasma cells

M-protein in the cell wall of the streptococcus

induces the immune system to cross react and
causes tissue injury to normal body cells due to
Molecular Mimicry

Cross reaction occurs with cardiac myosin and

antigens of tissue glucoprotein in the joints,
skin, brain and other connective tissues

Dx Tests and Induces cytokine

Lab release
Fever
-JONES
Criteria
Migratory
-ASO Titer polyarhtritis
Inflammatory
-ESR,CRP response

-WBC Increased WBC

-ECG
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Multi-systemic effects

Binds to
Autoimmune
receptors
Response attacks
Increased in the
the heart valves
ESR,CRP synovial
joint

Inflammation of the
layers of the heart
Collection Autoimmune
of Response
collagen
fibers
over the Difficulty of
heart to pump

Inflammation

Subcutaneous
Nodules
Increase cardiac
work load

(+) Joint pains

Scarring of the heart

valves that damage (Mitral
or Aortic valve)

Leaflet thickening,
commissural fusion,
shortening and thickening
of tendinous chords

Stagnation of blood

Tissue ischemia disrupts

normal cardiac electrical
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Chest pain ST segment elevation

Atrial fibrillation

Legend:

Manifestation Mechanism

Dx test and lab

Medical Management

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 Erythromycin (Antibiotic) for streptococcal infection in cases of

penicillin allergy
 Prednisone (Corticosteroids) has anti-inflammatory effects and
suppress the immune system’s attack
 Aspirin (Salicylate) anti-inflammatory and reduces the ability of
blood to clot and also as a precaution to avoid stroke since the
patient has experienced atrial fibrillation
 IV fluid therapy is used to preserve homeostasis when enteral
consumption is deficient (or absorption is impaired) and to
compensate for any additional losses. D5LR
 Order for Laboratory Tests (CBC, ESR, CRP, Creatinine, BUN, ASO
Titer, Troponin). Laboratory tests are done to diagnose, treat,
manage, or monitor a patient’s condition.
 Vital signs with O2 sat every 4 hours. Vital signs can be used to
easily assess the severity of an illness and how well the body is
dealing with the resulting physiological discomfort. Monitoring
oxygen saturation is vital for the prediction of the patient’s
tissue oxygen status.
 12 Lead ECG. It collects electrical signals from the heart. It's a
common and painless test used to diagnose heart problems easily
and check the heart's well-being.
 Complete bed rest without toilet privileges. Bed rest reduces
oxygen uptake and demand; allows for temporary compensation
 Attaching patient to a cardiac monitor. This helps when long-term
surveillance of symptoms that appear less than daily is needed.
Continuous heart monitoring allows for the early detection and
treatment of cardiac arrhythmias and other symptoms.

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Pharmacologic Management

Ciprofloxacin

Brand Name: Cipro IV

Chemical/Therapeutic Classification: Quinolone Antibiotic

Indication: Effective against many gram-positive and gram-

negative bacteria, for respiratory tract infections, bone, and joint
infections, skin, and skin structure infections

Dosage: 500 mg every 8 hours

Route: IVTT

Drug Action: Synthetic quinolone is a broad-spectrum

bactericidal agent. Inhibits DNA-gyrase, an enzyme necessary for
bacterial DNA replication and some aspects of transcription,
repair, recombination, and transposition.

Side Effects: nausea, vomiting, stomach pain, heartburn, diarrhea,

vaginal itching and/or discharge, pale skin, unusual tiredness,
sleepiness

Adverse Reactions:
GI: Nausea, vomiting, diarrhea, cramps, gas, pseudomembranous
colitis. 
Metabolic: Transient increases in liver transaminases, alkaline
phosphatase, lactic dehydrogenase, and eosinophilia count. 
Musculoskeletal: Tendon rupture, cartilage erosion.
CNS: Headache, vertigo, malaise, peripheral neuropathy, seizures
(especially with rapid IV infusion).
Skin: Rash, phlebitis, pain, burning, pruritus, and erythema at the
infusion site. 
Special Senses: Local burning and discomfort, crystalline precipitate
on the superficial portion of the cornea, lid margin crusting, scales,
foreign body sensation, itching, and conjunctival hyperemia.

Nursing Responsibilities:

 Before starting therapy, schedule culture and sensitivity tests.

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 After the signs and symptoms of infection have faded, continue

treatment for another two days.
 Ascertain that the patient is properly hydrated.
 Give antacids at least 2 hours after taking the medication.
 Monitor clinical response; if there is no improvement or a
relapse, repeat culture and sensitivity testing.
 Encourage the patient to complete the entire course of treatment.
 Nausea, vomiting, abdominal pain (eat frequent small meals);
diarrhea or constipation; drowsiness, blurring of vision,
dizziness; drowsiness, blurring of vision, dizziness; drowsiness,
blurring of vision, dizziness; drowsiness, blurring of vision,
dizziness; drowsiness, blurring of vision, dizziness (observe
caution if driving or using dangerous equipment).
 Report any rash, vision changes, severe GI issues, weakness, or
tremors.

Meloxicam

Brand Name: Mobic

Chemical/Therapeutic Classification: NSAID, Analgesic

Indication: Relief of the signs and symptoms of osteoarthritis,

rheumatoid arthritis

Dosage: 15 mg OD

Drug Action: This is a nonsteroidal anti-inflammatory drug (NSAID)

that exhibits anti-inflammatory, analgesic, and antipyretic
activities. The mechanism of action, like other NSAIDs, may be related
to prostaglandin synthetase (cyclooxygenase) inhibition.

Side Effects: stomach upset, nausea, drowsiness, diarrhea,

bloating, gas, dizziness, nervousness, headache, runny or stuffy nose,
sore throat, or skin rash.

Adverse Reactions:

Body as a Whole: Edema, fall, flu-like syndrome, pain. 

GI: Abdominal pain, diarrhea, dyspepsia, flatulence, nausea,

constipation, ulceration, GI bleed.

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 Hematologic: Anemia.

 Musculoskeletal: Arthralgia.

 CNS: Dizziness, headache, insomnia.

 Respiratory: Pharyngitis, upper respiratory tract infection,

cough. 

Skin: Rash, pruritus.

 Urogenital: Micturition frequency, urinary tract infection.

Nursing Responsibilities:

• Keep an eye out for signs and symptoms of GI ulceration or bruising,

such as dark, tarry stool, abdominal or stomach pain; hepatotoxicity,
such as weakness, lethargy, pruritus, jaundice, flu-like symptoms;
skin rash; weight gain, and edema; and hepatotoxicity, such as
exhaustion, lethargy, pruritus, jaundice, and flu-like symptoms; skin
rash; and weight gain and

• If hepatotoxicity or GI bleeding is detected, stop taking the

medication and call the doctor.

• When on this drug, do not allow the patient to take aspirin or other
NSAIDs.

Aspirin

Brand Name: Alka-Seltzer, A.S.A., Aspergum

Chemical/Therapeutic Classification: Salicylate, Antiplatelet

Indication: Also for various inflammatory conditions, such as

acute rheumatic fever; also used for RHD to reduce the risk of stroke
and other complications

Dosage: 1000 mg PO TID

Drug Action: Reduces inflammation and pain, also inhibits

platelet aggregation, reducing the ability of blood to clot.

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Side Effects: rash, gastrointestinal ulcerations, abdominal pain,

upset stomach, heartburn, drowsiness, headache, cramping, nausea,
gastritis, and bleeding

Adverse Reactions:

Body as a Whole: Hypersensitivity (urticaria, bronchospasm,

anaphylactic shock (laryngeal edema).

CNS: Dizziness, confusion, drowsiness. 

Special Senses: Tinnitus, hearing loss. 

GI: Nausea, vomiting, diarrhea, anorexia, heartburn, stomach

pains, ulceration, occult bleeding, GI bleeding. 

Hematologic: Thrombocytopenia, hemolytic anemia, prolonged

bleeding time. 

Skin: Petechiae, easy bruising, rash. Urogenital: Impaired renal

function. 

Nursing Responsibilities:

 Symptoms include profuse rhinorrhea, erythema, nausea, vomiting,

intestinal cramps, and diarrhea, which usually manifest 15
minutes to 3 hours after consumption.
 Lab tests: frequent PT and IRN with concurrent anticoagulant
therapy;
 Keep an eye out for salicylate toxicity. The most common symptoms
of chronic salicylate overdosage in adults are a feeling of
fullness in the head, tinnitus, and reduced or muffled hearing.

Prednisone

Brand Name: Deltasone, Meticorten, Orasone, Panasol, Prednicen-

M, Sterapred

Chemical/Therapeutic Classification: ADRENAL

CORTICOSTEROID; GLUCOCORTICOID

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Indication: used in the treatment of inflammatory conditions and

as an immunosuppressant

Dosage: 40 mg PO OD

Drug Action: Immediate-acting synthetic analog of hydrocortisone

Side Effects: headache, dizziness, difficulty falling asleep or

staying asleep, inappropriate happiness, extreme changes in mood,
changes in personality, bulging eyes, acne, thin fragile skin, red or
purple blotches or lines under the skin, slowed healing of cuts and
bruises, increased hair growth, changes in the way fat is spread
around the body, extreme tiredness, weak muscles, irregular or absent
menstrual periods, decreased sexual desire, heartburn, increased
sweating

Adverse Reactions:

CNS: Euphoria, headache, insomnia, confusion, psychosis.

CV: CHF, edema. GI: Nausea, vomiting, peptic ulcer.
Musculoskeletal: Muscle weakness, delayed wound healing, muscle
wasting, osteoporosis, aseptic necrosis of bone, spontaneous
fractures. 
Endocrine: Cushingoid features, growth suppression in children,
carbohydrate intolerance, hyperglycemia. 
Special Senses: Cataracts.
 Hematologic: Leukocytosis.
 Metabolic: Hypokalemia.

Nursing Responsibilities:

 Keep track of the blood pressure, I&O ratio and pattern, weight,
fasting blood glucose level, and sleep pattern.
 At least twice daily during the dosage stabilization time,
monitor and report the blood pressure. An ascending pattern
should be recorded.

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 Laboratory tests: During long-term steroid treatment, obtain

fasting blood glucose, serum electrolytes, and normal laboratory
experiments at regular intervals.
 Be on the lookout for hypocalcemia symptoms. Hypocalcemic
patients have higher needs for pyridoxine (vitamin B6), vitamins
C and D, and folates.
 Be on the lookout for masked infection and delayed recovery
(antiinflammatory and immunosuppressive actions). Early classic
symptoms of inflammation are suppressed by prednisone. Oral
Candida infection is common when a patient is on an extended
therapy schedule. Examine the mouth regularly for signs such as
white patches, a black furry tongue, and tender membranes and
tongue.

Erythromycin

Brand Name: Akne-Mycin Ery-Tab, A/T/S, E-Mycin, Eryc, EryDerm, Ery

Pads, EryTab, Erythrocin

Chemical/Therapeutic Classification: ANTIINFECTIVE; MACROLIDE

ANTIBIOTIC

Indication: Considered an acceptable alternative to penicillin

for treatment of streptococcal pharyngitis, for prophylaxis of
rheumatic fever, and bacterial endocarditis

Dosage: 500 mg BID

Drug Action: Bacteriostatic or bactericidal, depending on the

nature of organism and drug concentration used.

Side Effects: nausea, vomiting, diarrhea, stomach pain or

cramping, loss of appetite, and heartburn

Adverse Reactions:

GI: Nausea, vomiting, abdominal cramping, diarrhea, heartburn,

anorexia.

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SY 2020-2021, 2ND SEMESTER
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  Body as a Whole: Fever, eosinophilia, urticaria, skin eruptions,

fixed drug eruption, anaphylaxis. Superinfections by nonsusceptible
bacteria, yeasts, or fungi. 
Special Senses: Ototoxicity: reversible bilateral hearing loss,
tinnitus, vertigo.
  Digestive: (Estolate) Cholestatic hepatitis syndrome. 
Skin: (topical use) Erythema, desquamation, burning, tenderness,
dryness or oiliness, pruritus.

Nursing Responsibilities:

 Inform the doctor about the onset of GI symptoms after PO

administration. These are dose-related; if symptoms continue
after reducing the dosage, the doctor can recommend the
medication to be taken with meals despite reduced absorption.
 Keep an eye out for any negative GI results. Pseudomembranous
enterocolitis, which can be fatal, can occur before or after
antibiotic therapy.
 Look for S&S of superinfection caused by nonsusceptible bacteria
or fungus overgrowth.
 Lab examinations: During long-term treatment, periodic liver
function tests are performed.
 Keep an eye out for signs and symptoms of hepatotoxicity.
Abdominal pain, nausea, vomiting, fever, leukocytosis, and
eosinophilia are all symptoms of premonitory S&S; jaundice may or
may not be present. Symptoms may appear a few days after starting
the drug, but they normally appear after 1–2 weeks of regular
therapy. The symptoms are reversible if the erythromycin is
stopped immediately.

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Nursing Care Management

Nursing Problems

1. Acute Pain in joints related to inflammation evidenced by pain

with movement and verbal description of pain
2. Risk for decreased cardiac output related to altered myocardial
contractility evidenced by variation in hemodynamic parameter,
arrhythmia, and dyspnea
3. Hyperthermia related to inflammatory response as evidenced by an
increase in body temperature greater than the normal range

Nursing Management

1. Acute pain
 Assist with proper positioning and handling of affected parts
 Administer the medication for pain relief as prescribed
 Teach the pt. about guided imagery, relaxation (through
meditation, music therapy, and deep breathing), distraction
 Teach the pt. to apply heat applications
 Advise positional changes every 2-3 hours while maintaining body
alignment
 Highlight the importance of limited activity or amount of joint
movement allowed during the acute phase
 Teach the pt. about guided imagery, relaxation (through
meditation, music therapy, and deep breathing), distraction

2. Decreased cardiac output

 Administer supplemental oxygen as indicated

 Monitor blood pressure, apical pulse, and peripheral
pulses
 Monitor cardiac rhythm as indicated
 Listen to heart sounds(rate, rhythm, presence of s3 and
s4, and lung sounds)
 Promote bed rest with the head of the bed at least 45
degrees

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SY 2020-2021, 2ND SEMESTER
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 During acute events, ensure the patient remains on bed

rest or maintains an activity level that does not
compromise cardiac output
 Provide routine comfort measures ( shower/bath, position
change)
 Note chest pain. Identify location, radiation, severity,
quality, duration, associated manifestations such as
nausea and precipitating and relieving factors
 Monitor bowel function. Provide stool softeners as
ordered.
 Inform patient to avoid straining when defecating

3. Hyperthermia
 Provide tepid sponge bath as needed
 Note presence or absence of sweating as the body attempts
to increase heat loss by evaporation
 Promote bed rest, encourage relaxation and diversional
activities
 Promote surface cooling, loosen clothing, and cool
environment
 Administer replacement of fluids
 Administer medication as indicated (antipyretic)

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SY 2020-2021, 2ND SEMESTER
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SUBJECTIVE OBJECTIV NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED EVALUATION

E DIAGNOSIS ANALYSIS OUTCOME
“Nikalit Vital Acute pain In rheumatic After 6 hours of 1. Assist with [Link] 1. Relief -
lang ug signs in joints fever, the nursing proper pain and from Demonstrate
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tuhod” “ 37.8 n evidenced attacks able to: affected parts ation activities
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wala, nya description as the pharmacological prescribed and 10 to strategies
sa tuhod of pain protein found pain relief provides decreas (Met)
na pud in group A strategies [Link] the rest and e to 7
nisakit” beta- -Exhibit comfort patient to comfort -Exhibit
as hemolytic - perform deep comfort(Met
verbalized streptococcus Verbalize/manife breathing 3. Deep )
by the (due to sts an absence breathing -
patient molecular of pain with [Link] the pt. reduces mus Verbaliz
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of 10 out the antigen imagery, thereby sts an
of 10 reacts with relaxation lessening p absence
the host’s (through ain. of pain
proteins meditation, with
similar to music therapy), [Link] of movement
that of the distraction such ways (Met)
bacteria, it would help
activates the [Link] the the pt.
autoreactive patient to apply divert his
B and CD-4 T heat attention
cells. One of applications from the
the pain and
structures 6. Advise decreases
involved positional the effects

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 ST. PAUL UNIVERSITY DUMAGUETE
COLLEGE OF NURSING
SY 2020-2021, 2ND SEMESTER
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SUBJECTIVE OBJECTIV NURSING SCIENTIFIC PLANNING INTERVENTIONS RATIONALE EXPECTED EVALUATION

E DIAGNOSIS ANALYSIS OUTCOME
includes the changes every 2- of stress
proteins in 3 hours while on pain
the joints maintaining body
(vimentin) alignment [Link] is
and whenever used to
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produced importance of improving
attaches limited activity blood flow
itself to the or amount of to the area
synovial joint movement and through
joints it allowed during reduction
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inflammation reflexes
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exacerbatio
n of pain

[Link]
anxiety and
fear of any
irreversibl
e damage

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SY 2020-2021, 2ND SEMESTER
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SY 2020-2021, 2ND SEMESTER
______________________________________________________________________

SUBJECTI OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIO RATIONALE EXPECTED EVALUATIO

VE DIAGNOSIS ANALYSIS NS OUTCOME N
The ECG: ST- Risk for Due to the Short term [Link] 1. Provides [Link] -
segment immune goal: r optimal will Demonstra
patient decreased
elevation system After 15 supplementa oxygen for verbalize ted
complain (Ventricu cardiac attacking minutes of l oxygen as myocardial chest pain feelings
lar rate and nursing indicated uptake in has free from
s of output
of 81 infiltrating interventi an attempt relieved chest
slight bpm, 65 related to the heart ons the [Link] to pain and
bpm, 100 valves and pt. will blood compensate [Link] dyspnea
chest altered
bpm, and layer, be able pressure, for ory rate (Met)
pain 71 bpm) myocardial rheumatic to: apical increasing will -
and vegetation pulse, and oxygen stabilize Decreased
contractil
atrial activates -Demonstra peripheral demand to 21 episodes
fibrillat ity the te pulses of
ion fibroblasts feelings [Link] dyspnea,
evidenced
R: 28,21 to produce free from [Link] g enable chest
BP:150/80 by fibrous chest pain cardiac early pain, and
tissue and and rhythm as detection arrhythmi
, 120/90 variation
leads to dyspnea indicated and as
in getting the treatment through
valves Long term [Link] to of proper
hemodynami
inflamed, goal: heart decompensat intervent
c when this After 3-4 sounds ion ion (Met)
occurs, the days the (rate, - Patient
parameter,
heart's pt. will rhythm, [Link] explained
arrhythmia ability to be able presence of a such as actions
pump is to: s3 and s4 atrial and
, and
affected and and lung fibrillatio precautio
dyspnea so will the -Decrease sounds) n is the ns to
blood flow. episodes most common take
When cardiac of [Link] arrhythmias (Met)
cells lack dyspnea, bed rest in patients
oxygen they chest with the with ST-

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SY 2020-2021, 2ND SEMESTER
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SUBJECTI OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIO RATIONALE EXPECTED EVALUATIO

VE DIAGNOSIS ANALYSIS NS OUTCOME N
become pain, and head of the segment
depolarized arrhythmia bed at elevation
which leads s through least 45
to altered proper degrees [Link] new
impulse interventi onset of
formation on [Link] gallop
and altered -The acute rhythm and
impulse patient events, fine
contraction. explains ensure the crackles
(Klabunde,20 actions patient may
and remains on indicate
12)
precaution bed rest or the onset
s to take maintains of heart
an activity failure
level that
does not [Link]
compromise blood
cardiac volume
output returning
to the
[Link] heart
routine (preload),
comfort which
measures increases
( shower/ba oxygenation
th, and may
position reduce,
change) decreases
dyspnea and
8. Note cardiac
chest pain. strain
Identify

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SUBJECTI OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIO RATIONALE EXPECTED EVALUATIO

VE DIAGNOSIS ANALYSIS NS OUTCOME N
location, [Link]
radiation, on of
severity, activity
quality, facilitates
duration, temporary
associated recompensat
manifestati ion
ons such as
nausea and [Link]
precipitati redirect
ng and attention
relieving and
factors promotes
relaxation,
9. Monitor enhancing
bowel coping
function. activities
Provide
stool [Link]
softeners pain is
as ordered. suggestive
of an
[Link] inadequate
patient to blood
avoid supply to
straining the heart,
when which can
defecating compromise
cardiac
output

[Link]

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SUBJECTI OBJECTIVE NURSING SCIENTIFIC PLANNING INTERVENTIO RATIONALE EXPECTED EVALUATIO

VE DIAGNOSIS ANALYSIS NS OUTCOME N
activity
can cause
constipatio
n.
[Link]
g may
result in a
Valsalva
maneuver.

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SUBJECTI OBJECTI NURSING SCIENTIFIC PLANNING INTERVENTIO RATIONALE EXPECTED EVALUATION

VE VE DIAGNOSIS ANALYSIS NS OUTCOME
Vital Hypertherm With the After 2 [Link] [Link] [Link] -
signs ia related entry of hours of tepid reduce the will have a Demonstrate
to bacteria nursing sponge bath occurrence normal d
T: inflammato in the interventio as needed of fever range of temperature
38.5, ry systemic n, the and helps body within a
37.8 response circulatio patient’s [Link] bring the temperature normal
RR: as n, it temperature presence or temperature And will range(Met)
28,21 evidenced starts to will absence of down continue to -
by an regulate decrease sweating as stabilize Demonstrate
increase toxins in and pt. the body [Link] d behaviors
in body the body will be attempts to on is to monitor
temperatur and able to: increase decreased and promote
e greater releases heat loss by normothermi
than the pyrogen - by environment a (Met)
normal then Demonstrate evaporation al factors -Verbalized
range consequent temperature of high understandi
ly within [Link] humidity ng of
stimulates normal bed rest, and high specific
the range encourage ambient interventio
hypothalam - relaxation temperature ns to
us to Demonstrate and as well as prevent
increase behaviors diversional body hyperthermi
the body’s to monitor activities factors a (Met)
temperatur and promote producing
e. normothermi [Link] loss of
(Guilerme, a surface ability to
et -Verbalize cooling, sweat
al,2021) understandi loosen
ng of clothing, [Link] reduce
specific and cool metabolic
interventio environment demands
ns to

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SUBJECTI OBJECTI NURSING SCIENTIFIC PLANNING INTERVENTIO RATIONALE EXPECTED EVALUATION

VE VE DIAGNOSIS ANALYSIS NS OUTCOME
prevent [Link] [Link] is
hyperthermi r lost by
a medication evaporation
as and
indicated conduction
(Aspirin)
[Link]
inflammatio
n and pain
and has
antipyretic
effects

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Progress Notes

Problem Medical Nursing Outcome

Intervention Intervention
March Joint pain -D5LR 1L x -Assisted with From a pain
24, (patient is 33 gtts/min proper scale of 10 out
2021 experiencing -Meloxicam positioning and of 10 to 7 out
migratory 15 mg OD handling of of 10
polyarthritis) affected parts - Vital
- Patient signs of:
performed deep
breathing 8:00 AM
- Taught the T:38.5OC
patient to P:111
apply heat R:28
applications BP:150/80
- Taught the
patient about 12 NN
guided imagery T:37.8OC
and distraction P:99
-Administration R:21
of IVTT BP:120/90
medication
-IVF patent and
infusing well.
No signs of
infiltration
and redness

March Chest pain -Troponin -Administer -Negative

25, (ECG result: stat supplemental Troponin
2021 ST-segment -Aspirin oxygen as - Vital
elevation, 1000mg PO indicated signs of:
Atrial TID -Bed rest with
fibrillation -Repeat 12 the head of the 8:00 AM
upon follow up lead ECG bed at least 45 T:38.5OC
ECG) -Complete degrees P:111
bed rest - Provided R:28
without routine comfort BP:150/80
toilet measures
privileges (shower/bath, 12 NN
-Attached to position T:37.8OC
a cardiac change) P:99
monitor - Administered R:21
other PO BP:120/90
medications -IVF patent and
-Obtained ASO infusing well.
titer No signs of
infiltration
and redness

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Discharge Plan

Medication

Upon discharge, the patient may be asked to take prophylactic

therapy, benzathine benzylpenicillin, intramuscularly (with a
bodyweight > 20 kg – 1.2 MIU) for about 10 years or until 40 years of
age. Ensure that the patient understands the purpose, dosage, route,
and possible side effects of all the home-prescribed medications.
Instruct patient as well as family to strictly follow the take-home
medications and take them as a full course as prescribed by the
doctor. After 2-3 weeks of taking prednisone, tapering may begin
slowly, with a daily dose at the rate of 5 mg every 2-3 days. Once
tapering is started, aspirin at 75 mg/kg/day should be added and
continued for 6 weeks after prednisone is stopped. Prophylactic
antibiotics before dental and surgical procedures would reduce the
possibility of bacterial endocarditis.

Exercise

Encourage patient to do any activity with restrictions, resuming

activity gradually and resting whenever tired. Advise patient when
ambulating to have assistance and support as tolerated and to perform
ADLs which includes hygiene and self-care with support if needed by
pt.

Treatment

Emphasize the importance of prophylaxis against recurrent

streptococcal pharyngitis and continuous therapy to decrease
recurrence of Rheumatic fever and RHD. Explain the importance of
continuing home medications as prescribed. Family members should be
provided with enough knowledge and facilities to allow them to follow
basic infection prevention practices, such as proper hand hygiene, and
environmental cleaning.

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Health Education

Explain to the patient and family the disease process and its
treatment for promotion of understanding of its acute and lifelong
prophylactic treatment.

Advise patient to gradually return to physical activities with

the guidance of a physician.

Teach patient and family the importance of adhering to strict

hand hygiene, standard infection control practice; and the patient’s
used linen and waste should be considered infectious and handled
properly; Baths and bidet facilities should be cleaned and
decontaminated especially if a family member will use it afterward.

Encourage a relaxing environment by the use of relaxation

techniques like listening to music.

Encourage the patient to have frequent naps and rest periods.

Advise patient that he cannot return to work until health care

provider assesses that all disease activity is absent.

Outpatient

Instruct the patient to return to the doctor after 1 week for his
follow-up visit and most importantly every 21 days for maintenance of
treatment ( penicillin G benzathine, 1.2 million units given
intramuscularly). However, since the patient is allergic to
penicillin, treatment with Erythromycin stearate (250 mg BID) will be
given(Congeni, 1992). The patient will be re-cultured at the end of
treatment.

Diet

Encourage pt. to eat a variety of nutritious food, with limited

intake of sodium.

Spirituality

Support the patient with their faith tradition.

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CHAPTER V

CONCLUSIONS AND RECOMMENDATIONS

Conclusions

Rheumatic heart disease, although common to the young age group

or children, it still has a high probability of affecting other age
groups that may have living conditions predisposing them to Rheumatic
fever and also would greatly affect people who have a history of
smoking and drinking. The specific case of the patient may not have
any history of smoking and alcohol consumption, but his living
conditions and poor observance of proper hand hygiene and infection
control have the highest probability of him acquiring the Group A
beta-hemolytic streptococcus. Symptoms will start as a sore throat
that is recurrent and if this is not properly treated, will lead to
the progress of disease known as Rheumatic Heart Disease(RHD).

Recommendations

For the age group at risk (5-15 yrs) and people at higher risk
due to environmental factors, to observe proper hygiene, starting with
washing their hands properly to prevent the spread of infection;
proper handling of food and eating utensils, handling used linens and
materials used by a person who had a history of strep infection
properly. For those who experience sore throat especially if it is
recurrent to have it checked and treated promptly.

For the student nurse, they can improve the information in this
case study to help the population greatly affected with Rheumatic
fever and those at risk of GABHS (Group A Beta-hemolytic
Streptococcus).

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